1. Health Insurance Marketplaces
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2. What is Health Care Reform?
The Affordable Care Act (ACA) was enacted in March 2010.
Biggest overhaul of the United States’ health care system since Medicare and Medicaid in 1965
Requires most individuals to obtain health care coverage
Requires insurance companies and employers to provide consumer protections related to health coverage, like covering pre-existing conditions and not charging more for coverage based on an individual’s gender
The Affordable Care Act (ACA, PPACA, Obamacare ) was enacted in March 2010 and is the biggest overhaul of the United States’ health care system since the passage of Medicare and Medicaid in 1965.

3. Goals of the Affordable Care Act
Increase the quality and affordability of health insurance
Lower the uninsured rate
Reduce costs of health care
The goal of the ACA is to increase the quality and affordability of health insurance, lower the uninsured rate and reduce the costs of health care.

4. What are the Marketplaces?
Health Insurance Marketplaces (Exchanges) create alternative markets for buying health insurance.
They will:
Offer a choice of different health plans
Certify plans that participate
Provide information to help consumers understand their coverage options
Individuals can purchase insurance through a Marketplace if they are:
Not currently incarcerated
A lawful citizen or U.S. resident
Living in the service area of the Marketplace
Health Insurance Marketplaces (also known as Exchanges) are new organizations that will be set up to create alternative markets for buying health insurance.
They will offer a choice of different health plans, certify plans that participate and provide information to help consumers understand their coverage options.
In order to be eligible, you must not be incarcerated, and you must be a lawful U.S. citizen, and live in the service area of the Marketplace.

5. Important dates For coverage starting in 2015,
Open Enrollment Period is November 15, 2014–February 15, 2015.
Individuals may also qualify for Special Enrollment Periods outside of Open Enrollment if they experience certain events.
(See Special Enrollment Period and Qualifying Life Event)
The Marketplaces are set to be operational beginning on Jan. 1, 2014, with enrollment beginning on Oct. 1, In order to have coverage by Jan. 1, 2014, you must make your elections by Dec. 15, 2013.
DANA change dates

6. Employer coverage Employer Coverage vs. Exchange Coverage
The coverage offered through the employer is likely more affordable than coverage purchased through the Exchange.
Exchange coverage is a good option if you qualify for premium subsidiaries or out-of-pocket assistance.
The coverage that you receive through your employer is likely to be much more affordable than most coverage you can get through the exchanges because your employer probably contributes a fair amount of money toward that coverage each month. In addition, because it is group coverage, employer plans can often get better rates.
However, if you are ineligible for coverage through your employer, purchasing coverage through an exchange could be a great option for you.

7. Shopping for coverage
To apply for coverage, compare plans and enroll, most people will access the Exchange (Marketplace) through
For states with their own health insurance marketplaces, you will access your state-specific portal.
If you reside outside of the 50 states, check with your territory’s government offices to learn about health coverage options.
Links can be found at Healthcare.gov for states that require a state-specific portal.

8. Exchange map Marketplace Statistics:
Twenty-six states running federally facilitated marketplaces
Sixteen state-run marketplaces
Seven states have a state-federal partnership, with states running plan management and consumer assistance
Utah: A hybrid system with the state running the small business marketplace, federal running the individual marketplace.

9. What types of plans will be available?
There are four categories of Marketplace insurance plans:
Bronze
Silver
Gold
Platinum
Catastrophic plans available to people under 30 and those with very low incomes.
The category you choose affects how much your premium costs each month and what portion of the bill you pay for things like hospital visits or prescription medications. It also affects your total out-of-pocket costs.
Specific coverage can vary depending on your state’s benchmark.
All Marketplace insurance plan categories offer the same set of essential health benefits. The categories do not reflect the quality or amount of care the plans provide.

10. What do the plans cover
All plans will cover a comprehensive package of items and services known as essential health benefits:
Ambulatory patient services (outpatient care w/out being admitted to a hospital)
Emergency services
Hospitalization (including surgery)
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
Insurance policies must cover these 10 benefits in order to be certified and offered in the Health Insurance Marketplace.
Ambulatory patient services (outpatient care you get without being admitted to a hospital)
Emergency services
Hospitalization
Maternity and newborn care (care before and after your baby is born)
Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
Prescription drugs
Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services Essential health benefits are minimum requirements for all plans in the Marketplace. Plans may offer additional coverage. You will see exactly what each plan offers when you compare them side by side in the Marketplace.

11. How will I know which plan is right for my employees?
Premiums are usually higher for plans that pay more of your out-of-pocket medical costs when you get care.
If you have a Platinum plan, you'll likely pay a higher premium and have lower costs when you go to the doctor.
When choosing your health plan, keep these general rules in mind:
The lower the premium, the higher the out-of-pocket costs when you need care.
The higher the premium, the lower the out-of-pocket costs when you need care.
Do you need regular prescriptions or expect a lot of doctor visits?
If so, then you may want a Platinum or Gold plan.
If you don’t, you may prefer a Silver or Bronze plan.
The right plan for you will depend on your own particular circumstances.

12. Who is eligible for SHOP?
There are specific requirements for an employer to be eligible for a SHOP
The employer’s primary business location be located in a SHOP’s service area (typically an entire state)
The employer must have at least one eligible employee on payroll
This excludes owners, including sole proprietors, and owners’ spouses and dependents on payroll
Qualified employers may enroll owners and owners’ spouses and dependents in a SHOP even though that are not included in eligibility determinations
The employer must have 50 or fewer full times equivalent (FTE) employees on payroll:
The FF-SHOPs must determine size by using FTEs, a method that includes part-time but not seasonal employees who work fewer than 120 days per year
While the FF-SHOPs must determine eligibility using the definitions above, State-based SHOP Marketplaces have flexibility in their counting approaches for 2014 and 2015
The SHOP FTE Calculator is available at Healthcare.gov to help count employees for purposes of determining who might be eligible for FF-SHOP.
Coverage must be offered to all full-time employees (Full-time is defined as working more than 30 hours per week)

13. SHOP Summary
The key points on employer application and enrollment are:
There are 8 steps for agents/brokers to help employers with FF-SHOP application and enrollment.
Important basis information about the employer’s business on the SHOP website or through the SHOP Agent Broker Portal
Create an employee roster with basic information about each employee
Employer reads information about each plan on the SHOP website
Employer determines whether to offer employees a single health plan or a choice of health plans within a given metal level or issuer beginning plan year 2015
Employer chooses a defined percentage of the reference plan to contribute for each employee (and if applicable, for dental coverage for each dependent)
Employer review summary of choices
Agents and brokers help employees enroll in SHOP
Employer reviews completed group enrollment
An employer must submit the first months premium after employees enroll
Employers pay an aggregated premium payment to SHOP directly beginning plan year 2015

14. SHOP Summary, continued
Additional key points are:
In 2015, small businesses that offer coverage through FF-SHOP may be able to offer their employees a choice of qualified health plans (QHPs) and qualified dental plans (QDPs)
To qualify for FF-SHOP, a business must be located in a FF-SHOP’s services area, offer coverage to all full-time employees, have at least one eligible employee on payroll, and have 50 or fewer FTE employees on payroll
The premium tax credit and cost-sharing reductions are not available to employers, employees, and their families covered through an FF-SHOP
Employers meeting certain size and average wage requirements may receive a small business health care tax credit to assist with the cost of health insurance coverage purchased through a SHOP

15. Required information
Marketplace Application Checklist—items required to enroll include:
Social Security numbers
Employer and income information for every member of your household who needs coverage
Policy numbers for any current health insurance plans covering members of your household
A completed worksheet—called an Employer Coverage Tool—for every job-based plan you or someone in your household is eligible for
When you apply for coverage in a Marketplace, you’ll need to provide some information about you and your household. It is a good idea to get this information together now so that you are ready when the time comes to enroll.
Items required to enroll include:
- Social Security numbers (or document numbers for legal immigrants)
- Employer and income information for every member of your household who needs coverage (for example, from wage and tax statements such as pay stubs or Forms W-2)
- Policy numbers for any current health insurance plans covering members of your household
A completed worksheet—called an Employer Coverage Tool—for every job-based plan you or someone in your household is eligible for. You’ll need to fill out this form even for coverage you’re eligible for, even if you are not enrolled.

16. Assistance
The Marketplace is complex, but will offer several kinds of assistance to help you apply for coverage and choose a plan that meets your needs:
Online questions and answers
Online chat
A toll-free call center
In all states, there will be people trained and certified to help you understand your health coverage options and enroll in a plan:
Your broker & insurance agents
Navigators
Application assistors
Certified application counselors
The launch of an entirely new system for obtaining health insurance is an extremely complex undertaking. The Marketplace will offer several kinds of assistance to help you apply for coverage and choose a plan that meets your needs:
Online questions and answers
Online chat
A toll-free call center
You can also get help locally—in all states, there will be people trained and certified to help you understand your health coverage options and enroll in a plan.
Your broker is your best bet when it comes to getting local personalized help in the individual marketplace.
Navigators
Application assistors
Certified application counselors

17. Subsidies
Subsidized coverage is available to some individuals and families with incomes up to 400 percent of the federal poverty level.
You can save money in the Marketplaces in two different ways:
Tax credits to help you pay premiums
Reduced out-of-pocket costs
Eligibility for subsidies will depend on your household income and family size.
Subsidized coverage—or coverage that’s obtained through financial assistance from programs to help people with low and middle incomes—is available to individuals and families with household incomes up to 400 percent of the federal poverty level.
You can save money in the Marketplaces several ways. All of them depend on your income and family size.
You may be able to lower costs on your monthly premiums through tax credits when you enroll in a qualified health plan.
You may qualify for lower out-of-pocket costs for copayments, coinsurance and deductibles.

18. Eligibility for subsidies
To be eligible for the subsidies, a taxpayer:
Must have household income for the year within the federal limits
May not be claimed as a tax dependent of another taxpayer
Must file a joint return, if married
You are not eligible for subsidies if:
Your employer offers affordable, minimum value health coverage
You enroll in your employer’s health plan
To be eligible for the subsidies, a taxpayer:
Must have household income for the year within the limits described above
May not be claimed as a tax dependent of another taxpayer
Must file a joint return, if married
You are not eligible for subsidies if:
Your employer offers you affordable, minimum value health coverage
You enroll in your employer’s health plan, whether it’s affordable/minimum value or not

19. Subsidies: tax credits
The Advanced Premium Tax Credit covers the amount between what households are required to pay and the cost of the insurance policy.
The credit is available for people with somewhat higher incomes (up to 400 percent of the federal poverty line (FPL)).
By far the most widely available subsidy is the Advance Premium Tax Credit, which helps people cover the gap between the cost of their premium and what they can afford to pay.
As mentioned before, you are not eligible for subsidies if your employer offers you affordable, minimum value health coverage or if you enroll in your employer’s health plan.

20. Subsidies: reduced out-of-pocket costs
Health insurance companies offering coverage through the Marketplace must reduce the amount you pay out of pocket for essential health benefits.
Available if your household income is at or below 250 percent of the federal poverty level.
Households that earn up to 250 percent of the federal poverty level may be eligible for cost-sharing subsidies. This results in reduced out-of-pocket costs for low and moderate income households.

21. Who’s eligible? Income Level Premium as a Percent of Income
Tax Credits (not exceed earnings below)
Up to $45,960 for individuals
Up to $62,040 for a family of two
Up to $78,120 for a family of three
Up to $94,200 for a family of four
Up to $110,280 for a family of five
Up to $126,360 for a family of six
Up to $142,440 for a family of seven
Up to $158,520 for a family of eight
Reduced out-of-pocket costs
Up to $28,725 for individuals
Up to $38,775 for a family of two
Up to $48,825 for a family of three
Up to $58,875 for a family of four
Up to $68,925 for a family of five
Up to $78,975 for a family of six
Up to $89,025 for a family of seven
Up to $99,075 for a family of eight
Income Level
Premium as a Percent of Income
Up to 133% FPL
2% of income
% FPL
3 – 4% of income
% FPL
4 – 6.3% of income
% FPL
6.3 – 8.05% of income
% FPL
8.05 – 9.5% of income
% FPL
9.5% of income
Tax credits:
Premium tax credits are both refundable and advanceable. A refundable tax credit is available to a person even if he or she has no tax liability. An advanceable tax credit allows a person to receive assistance at the time that he or she purchases insurance rather than paying his or her premium out of pocket and waiting to be reimbursed when filing an annual income tax return.
There are several online calculators available to help you estimate the size of your premium tax credit and the percentage of your income relative to the poverty level.
Reduced out-of-pocket costs:
Households that earn up to 250 percent of the federal poverty level may be eligible for cost-sharing subsidies.
For reduced out-of-pocket costs, reduced cost-sharing is only applicable to Silver plans. If you qualify for out-of-pocket savings, you must choose a Silver plan to get the savings.
The numbers here are based on 2013 numbers. They are likely to be slightly higher in 2014.

22. Reporting
Marketplaces will be required to report certain information to both the IRS and the taxpayer.
The information that the Marketplace will have to report includes:
The level of coverage (bronze, silver, gold or platinum)
Identifying information for the primary insured and each enrollee (such as Social Security number or birthdate)
The amount of premiums and advance credit payments for coverage
Information provided to the Marketplace necessary to determine eligibility for and amount of subsidies
Other information necessary to determine whether the taxpayer received the appropriate subsidies.
The Marketplace will provide a copy of the cumulative annual report to each taxpayer before Jan. 31 of the year following the year of coverage.
This reporting helps the Marketplace determine whether the taxpayer will need to repay any portion of the subsidy.
The Marketplace will make a monthly report of this information to the IRS for each month of coverage. In addition, the Marketplace will have to make a cumulative annual report for each taxpayer to the IRS before Jan. 31 of the following year.

23. Other resources www.healthcare.gov/subscribe
With these updates, you’ll know when there's important new information about the Marketplace and receive reminders about important dates.
@healthcaregov on Twitter
Watch and share videos about the Marketplace.
The Health Insurance Blog has tips for consumers and small businesses, top things to know about the Marketplace, frequently asked questions and more.